Death Beneficiary Form

LIFE ASSURANCE – EXPRESSION OF WISH Formatted: Centered

Employee Number (HRIS): ___________________ Date of Birth: _________________________

To be inserted by HRIS Specialist Formatted: Font: 8 pt

I, _______________________________________________________________________________, employee of Digicel

(FIRST NAME) (MIDDLE INITIAL) (LAST SURNAME)
(PNG) Limited, being of sound mind and body do hereby declare and direct that in the event of my death I give, devise
and bequeath all salary payments, accrued leave entitlements, benefits and any otherlife assurance entitlements owed to
me by the company to these beneficiaries apportioned as follows:
Name and Contact details of Beneficiary Birth Date Relationship to you Portion of
Benefit*
1 %
Phone:
Address:
2 %
Phone:
Address:
3 %
Phone:
Address:
4 %
Phone:
Address:
Total 100 %
*The sum of each of your portions of the total benefit must equal 100% and each portion must be provided in percentages. More beneficiaries may be added if
required.

Declaration
I understand that I it is my responsibility to review my nomination regularly and amend it as my circumstances change
(e.g. mMarriage, mMarriage breakdown, birth of a child) to ensure my nomination is always up to date and further
acknowledge and agree that this form shall be conclusive proof of my wishes with regards to sums owing to my estate by
Digicel (PNG) Limited and that this form revokes all previous wills or testamentary dispositions made before this date with
regards to any monies to be paid by Digicel (PNG) Limited.

Employee Name: _______________________________

Employee Signature: _______________________________ Date: _______________________________

SIGNED by the Testator as and for his/ her last Will and Testament with regards to the assets stated in the contents of
this form after the same had been read over and explained to him / her in the ___________________ language and he
appeared fully to understand the meaning and effect thereof in the presence of us both being present at the same time
and we at his /her request and in his / her presence and in the presence of each other have hereunto subscribed our
names as Witnesses:-

_______________________________ _______________________________
Non-Beneficiary Witness # 1 Signature Non-Beneficiary Witness # 2 Signature
_______________________________ _______________________________
Name Date: / / 20 Name Date: / / 20